: assessing the risk of fragility fracture bring together everything NICE says on a topic in an interactive flowchart. are interactive and designed to be used online. They are updated regularly as new NICE guidance is published. To view the latest version of this NICE Pathway see: http://pathways.nice.org.uk/pathways/osteoporosis NICE Pathway last updated: 07 February 2018 This document contains a single flowchart and uses numbering to link the boxes to the associated recommendations. Page 1 of 10
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: assessing the risk of fragility fracture 1 Person aged 18 or over presenting in any healthcare setting No additional information 2 Assessing a person starting treatments that affect bone density Consider measuring BMD with DXA before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer). 3 When to assess a person depending on age and sex Women aged 65 and over, and men aged 75 and over Consider assessment of fracture risk in all women aged 65 years and over and all men aged 75 years and over. Women aged 50 to 64, and men aged 50 to 74 Consider assessment of fracture risk in women aged under 65 years and men aged under 75 years in the presence of risk factors, for example: previous fragility fracture current use or frequent recent use of oral or systemic glucocorticoids history of falls family history of hip fracture other causes of secondary osteoporosis [See page 7] low BMI (less than 18.5 kg/m 2 ) smoking alcohol intake of more than 14 units per week for women and more than 21 units per week for men. For further information on falls, see what NICE says on preventing falls in older people. Page 3 of 10
: assessing the risk of fragility fracture Under 50s Do not routinely assess fracture risk in people aged under 50 years unless they have major risk factors (for example, current or frequent recent use of oral or systemic glucocorticoids, untreated premature menopause or previous fragility fracture), because they are unlikely to be at high risk. For further information on hip fracture, see what NICE says on hip fracture. Under 40s Measure BMD to assess fracture risk in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer). Quality standards The following quality statement is relevant to this part of the interactive flowchart. 1. Assessment of fragility fracture risk 4 Estimating absolute risk Estimate absolute risk when assessing risk of fracture (for example, the predicted risk of major osteoporotic or hip fracture over 10 years, expressed as a percentage). Use either FRAX (without a BMD value if a DXA scan has not previously been undertaken) or QFracture, within their allowed age ranges, to estimate 10-year predicted absolute fracture risk when assessing risk of fracture. Above the upper age limits defined by the tools, consider people to be at high risk. FRAX can be used for people aged between 40 and 90 years, either with or without BMD values, as specified. Qfracture can be used for people aged between 30 and 84 years. BMD values cannot be incorporated into the risk algorithm. Page 4 of 10
: assessing the risk of fragility fracture Interpret the estimated absolute risk of fracture in people aged over 80 years with caution, because predicted 10-year fracture risk may underestimate their short-term fracture risk. Factors that may affect the accuracy of risk assessment tools Take into account that risk assessment tools may underestimate fracture risk in certain circumstances, for example if a person: has a history of multiple fractures has had previous vertebral fracture(s) has a high alcohol intake is taking high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer) has other causes of secondary osteoporosis [See page 7]. Take into account that fracture risk can be affected by factors that may not be included in the risk tool, for example living in a care home or taking drugs that may impair bone metabolism (such as anti-convulsants, selective serotonin reuptake inhibitors, thiazolidinediones, proton pump inhibitors and anti-retroviral drugs). When to consider measuring bone mineral density Following risk assessment with FRAX (without a BMD value) or QFracture, consider measuring BMD with DXA in people whose fracture risk is in the region of an intervention threshold for a proposed treatment, and recalculate absolute risk using FRAX with the BMD value. Do not routinely measure BMD to assess fracture risk without prior assessment using FRAX (without a BMD value) or QFracture. NICE has published a medtech innovation briefing on Bindex for investigating suspected osteoporosis. 5 When to recalculate fracture risk Consider recalculating fracture risk in the future: if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years, or when there has been a change in the person's risk factors. Page 5 of 10
: assessing the risk of fragility fracture 6 Back to overview See / overview Page 6 of 10
: assessing the risk of fragility fracture Causes of secondary osteoporosis include: endocrine hypogonadism in either sex including untreated premature menopause and treatment with aromatase inhibitors or androgen deprivation therapy hyperthyroidism hyperparathyroidism hyperprolactinaemia Cushing's disease diabetes gastrointestinal coeliac disease inflammatory bowel disease chronic liver disease chronic pancreatitis other causes of malabsorption rheumatological rheumatoid arthritis other inflammatory arthropathies haematological multiple myeloma haemoglobinopathies systemic mastocytosis respiratory cystic fibrosis chronic obstructive pulmonary disease metabolic (homocystinuria) chronic renal disease and immobility (due for example to neurological injury or disease). Page 7 of 10
: assessing the risk of fragility fracture Glossary BMD bone mineral density DXA dual-energy X-ray absorptiometry Intervention threshold the level of risk at which an intervention is recommended; people whose risk is in the region from just below to just above the threshold may be reclassified if BMD is added to assessment (it was out of the scope of the osteoporosis: fragility fracture risk clinical guideline to recommend intervention thresholds; healthcare professionals should follow local protocols or other national guidelines for advice on intervention thresholds) SD standard deviations T-score T-score relates to the measurement of bone mineral density (BMD) using central (hip and/or spine) DXA scanning, and is expressed as the number of standard deviations (SD) from peak BMD Sources : assessing the risk of fragility fracture (2012) NICE guideline CG146 Page 8 of 10
: assessing the risk of fragility fracture Your responsibility Guidelines The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Technology appraisals The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian. Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to Page 9 of 10
: assessing the risk of fragility fracture have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Medical technologies guidance, diagnostics guidance and interventional procedures guidance The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties. Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible. Page 10 of 10